1. Integrating Behavioral Health into Wellness Visits in Pediatric Primary Care Jean Cobb, Ph.D. J. David Bull, Psy.D. Behavioral Health Consultants, Cherokee Health Systems Collaborative Family Healthcare Association 15 th Annual Conference October 10-12, 2013 Broomfield, Colorado U.S.A. Session #H3b Friday, October 11, 2013

2. © 2013 Cherokee Health Systems All Rights Reserved Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. © 2013 Cherokee Health Systems All Rights Reserved Objectives Describe an effective clinical model that implements behavioral health as a routine part of pediatric primary care Describe an effective clinical model that implements behavioral health as a routine part of pediatric primary care Identify screening instruments that are clinically useful and easily implemented Identify screening instruments that are clinically useful and easily implemented Demonstrate working relationships between BHC, patient/family, PCP, and medical staff Demonstrate working relationships between BHC, patient/family, PCP, and medical staff Illustrate a team approach to address prevention, identification, and treatment of behavioral health problems within pediatric primary care Illustrate a team approach to address prevention, identification, and treatment of behavioral health problems within pediatric primary care

4. © 2013 Cherokee Health Systems All Rights Reserved Overview and Rationale Well Child Checks Well Child Checks A routine part of pediatric wellness A routine part of pediatric wellness Longevity of care Longevity of care Many areas covered (medical, developmental, social, behavioral) Many areas covered (medical, developmental, social, behavioral) Challenges Challenges Busy schedules/ pace in pediatric primary care Busy schedules/ pace in pediatric primary care How to efficiently and effectively address prevention, identification, and treatment of behavioral health problems in pediatric primary care How to efficiently and effectively address prevention, identification, and treatment of behavioral health problems in pediatric primary care

5. © 2013 Cherokee Health Systems All Rights Reserved Role of BHC Member of primary care team Member of primary care team Screening, updating social history, anticipatory guidance Screening, updating social history, anticipatory guidance BHC as behavioral “expert” BHC as behavioral “expert” Addressing holistic needs of patients, while working to increase efficiency/flow Addressing holistic needs of patients, while working to increase efficiency/flow

6. © 2013 Cherokee Health Systems All Rights Reserved Screening Instruments Infant Development Inventory (IDI) Infant Development Inventory (IDI) Child Development Review (CDR) Child Development Review (CDR) Pediatric Symptom Checklist (PSC) Pediatric Symptom Checklist (PSC) Edinburgh Postnatal Depression Scale (EPDS) Edinburgh Postnatal Depression Scale (EPDS) Modified Checklist for Autism in Toddlers (MCHAT) Modified Checklist for Autism in Toddlers (MCHAT) Adolescent Drug & Alcohol Use: CRAFFT Adolescent Drug & Alcohol Use: CRAFFT

7. © 2013 Cherokee Health Systems All Rights Reserved Clinical Flow Nurse retrieves family from waiting room (vitals, place in exam room) Nurse retrieves family from waiting room (vitals, place in exam room) BHC reviews screening measures, reviews social history, and anticipatory guidance BHC reviews screening measures, reviews social history, and anticipatory guidance BHC documentation is part of PCP’s WCC encounter and note BHC documentation is part of PCP’s WCC encounter and note

8. © 2013 Cherokee Health Systems All Rights Reserved

9. © 2013 Cherokee Health Systems All Rights Reserved Clinical Flow Any concerns identified by screening measures, social history, or through clinical contact are addressed either through brief intervention or follow-up with BHC Any concerns identified by screening measures, social history, or through clinical contact are addressed either through brief intervention or follow-up with BHC BHC provides immediate feedback and synopsis of any interventions offered to PCP before entering room BHC provides immediate feedback and synopsis of any interventions offered to PCP before entering room

10. © 2013 Cherokee Health Systems All Rights Reserved Outcomes Enhanced quality of care Enhanced quality of care Implementation of consistent prevention component Implementation of consistent prevention component Improved identification and increased intervention for children at-risk Improved identification and increased intervention for children at-risk Increased primary care productivity Increased primary care productivity Enabling PCP to have more patient visits Enabling PCP to have more patient visits BHC service for WCC is billed as extension of PCP’s encounter BHC service for WCC is billed as extension of PCP’s encounter

11. © 2013 Cherokee Health Systems All Rights Reserved Case Examples 2 month-old, White male, mother has elevated score (11) on Edinburgh Postnatal Depression Scale 2 month-old, White male, mother has elevated score (11) on Edinburgh Postnatal Depression Scale 11 year-old, Hispanic male with BMI in the 83 rd percentile, was on 70 th percentile growth curve since age 6, gained 8 lbs in past year 11 year-old, Hispanic male with BMI in the 83 rd percentile, was on 70 th percentile growth curve since age 6, gained 8 lbs in past year 30 month-old, African American male, mother says “I am worried because he is not talking as much as his brother did at this age” 30 month-old, African American male, mother says “I am worried because he is not talking as much as his brother did at this age” 15 year-old, White female with elevated score (22) of PSC, father reports they have been “arguing a lot more than usual” 15 year-old, White female with elevated score (22) of PSC, father reports they have been “arguing a lot more than usual”

12. © 2013 Cherokee Health Systems All Rights Reserved Implementation Before implementing, anticipate that pediatric providers may express concerns: Before implementing, anticipate that pediatric providers may express concerns: – Disruption of clinical flow – Need for BHC expertise on topics typically covered by pediatricians Emphasize to team that goal is to improve clinic’s efficiency, while also enhancing patient visit Emphasize to team that goal is to improve clinic’s efficiency, while also enhancing patient visit

13. © 2013 Cherokee Health Systems All Rights Reserved Implementation Scheduling Scheduling – Make a 15 min block on BHC schedule for WCC – On provider’s schedule template schedule sick visits before and after WCC to maximize PCP work flow – If multiple providers try to stagger WCC by 15min, so BHC can be involved without disrupting clinical flow

14. © 2013 Cherokee Health Systems All Rights Reserved Implementation BHC must be aware of clinic flow – be an asset, not burden BHC must be aware of clinic flow – be an asset, not burden Obtain helpful patient handouts that cover common concerns (tantrums, baby blues, sleep problems, weight management etc.) Obtain helpful patient handouts that cover common concerns (tantrums, baby blues, sleep problems, weight management etc.) Make plan for when BHC is not available (train nurses on reviewing screening measures, completing social history, knowing when to refer to BHC) Make plan for when BHC is not available (train nurses on reviewing screening measures, completing social history, knowing when to refer to BHC)

15. © 2013 Cherokee Health Systems All Rights Reserved Discussion & Learning Assessment Jean.Cobb@cherokeehealth.comDavid.Bull@cherokeehealth.com

16. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!